Bloomington School District #87
BLOOMINGTON SCHOOL DISTRICT #87 PARENT PERMIT/INSURANCE WAIVER FORM
(This form, front and back, must be completely filled out prior to participation in any extracurricular activity)
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Student Name Grade Date of Birth
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Address City Zip Code
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Parent/Guardian Name Phone # Email Address
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Emergency Contact Relationship Phone #
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Family Doctor Phone # Hospital Choice
The athlete named above has my permission to compete in the sports indicated below for Bloomington District #87 during the 2017-2018 school year (mark all that may apply).
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PARENT/GUARDIAN SIGNATURE DATE
*Please list any type of medical information which might be needed in case of an emergency and that the coach should be aware of (allergies, medications the athlete may be taking such as inhalers or glucose, known medical conditions). The Parent and athlete are responsible for ensuring the athlete has any medicine with them for contests and practices and for administering any medicine to the athlete. ______
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INSURANCE:
District #87 is not responsible for Health Insurance Claims and each athlete must have their own insurance program to be eligible to participate in athletics.
The participant listed about is covered by health insurance for the 2017-18 academic year.
Name of Insurance Company: ______
The Expiration Date of our Current Coverage is (if listed on card): ______
In case of an emergency and I cannot be reached, I give my permission to have properly trained medical professionals treat my son/daughter.
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PARENT/GUARDIAN SIGNATURE DATE
Bloomington High School
Code of Conduct
Removal from SchoolSponsored Events and/or ExtraCurricular Activities
One of the major objectives of formal education is to teach the principles of good citizenship and of taking responsibility for one's actions at all times. For this reason the Bloomington High School Code of Conduct applies to each student for the entire calendar year (24/7 and 365).
- Students who display unacceptable behavior as described in the school’s Disciplinary Guidelines, whether or not such behavior is on school property, at a school sponsored event or activity, or when school is not in session, should not be entitled to the privilege of participating in activities designed to promote the image of the District 87 student body and prepare students for good citizenship. Therefore, students who display unacceptable conduct may be declared by the School Administration to be ineligible to participate in school-sponsored events and/or extracurricular activities for a period not to exceed three (3) school months.
- A committee consisting of the activity's head coach or sponsor, the Athletic Director, the Assistant Principal, and the Principal will meet to discuss and consider the facts, circumstances, type of offense and possible ineligibility. Three (3) of the four committee members must agree that ineligibility is appropriate and the length of the ineligibility. The committee may increase the length of ineligibility for subsequent infractions, conviction (or juvenile adjudication) of a crime, or the serious nature of the infraction. The committee will schedule the starting date of the ineligibility.
- The student shall cooperate with the committee to provide information and answer questions about the incident. The student and the student’s parents or guardians shall have an opportunity to present the student’s case and evidence to the committee.
- The Principal and Athletic Director may exclude a student charged with a serious crime pending completion of a legal investigation or conclusion of a trial.
- Individual teams, activities, and clubs may have more stringent rules. These shall be communicated to athletes in writing the first day of tryout or at the organizational meeting, and shall be returned signed by the parent before the student is allowed to attend the third day of tryouts or become an active participant.
- A student/athlete must be passing 5 classes each week to be eligible to compete in athletic contests. The athlete must also have passed 5 classes the previous semester to be eligible in the following semester.
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STUDENT SIGNATURE DATE
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PARENT/GUARDIAN SIGNATURE DATE